Forum shifting in global health security

Abstract Global health security is an increasingly complex regime. The failures of global governance and norms of cooperation during the coronavirus disease 2019 (COVID-19) pandemic and the re-entrenchment to nationalist policy-making have created impetus for new governance arrangements, institutions and policy development. These changes include amendments to the International health regulations (IHR), development of a pandemic convention or accord, convening of the High-Level Meeting on Pandemic Preparedness and Response, establishment of the Pandemic fund, and development of the medical countermeasures platform, among others. These various developments claim to be in synergy with each other, but understanding of regime complexes and forum shifting from international relations reveal the power dynamics which underlie these processes. I use these concepts to demonstrate how states are transferring negotiations from one institutional location to another in search of more favourable outcomes, or are creating strategic uncertainty within negotiations to avoid future accountability. I further highlight three risks posed by these developments: (i) an increasingly complex landscape for global health security; (ii) erosion of the World Health Organization’s authority in global health security; and (iii) dominance of high-income state positions within these negotiations.


Introduction
Global health security, defined by the World Health Organization (WHO) as "the activities required, both proactive and reactive, to minimize the danger and impact of acute public health events that endanger people's health across geographical regions and international boundaries," is increasingly complex. 1 Traditionally, WHO has been at the centre of global health security activities, as the international agency with the mandate "to act as the directing and coordinating authority on international health work." 2 WHO's current authority for global health security derives from the International health regulations (IHR), 2005. 3This authority includes: (i) requiring states to have certain core capacities in public health to be able to prevent, detect and respond to an emerging infectious disease; (ii) designating an event a Public health emergency of international concern and in doing so issuing temporary recommendations to states, including on travel and trade, to minimize the potential effects of the pathogen; (iii) allowing anyone to report a disease to WHO, a prerogative which was previously reserved only for states, although States Parties concerned need to verify the status; 3 and (iv) taking an allrisk approach to disease.Thus, WHO has the role of global health security coordinator. 4However, perceived failures with recent health emergencies, such as a failure to follow temporary recommendations of the IHR, have meant that the IHR and WHO's authority has been challenged [5][6][7] and, in parallel, new mechanisms and institutions are being developed that add to the governance landscape of global health security.These bodies include the World Bank, International Monetary Fund, World Trade Organization (WTO), United Nations (UN) General Assembly, philanthropic foundations and nongovernmental organizations.
In this paper, I use the concepts of regime complexes and forum shifting from the field of international relations to demonstrate that current global health security governance is increasingly a regime complex.][12] However, within the regime complex of global health security, states are still the driving force behind these arrangements, despite most policy development occurring within international organizations.However, this dominance of states leads to increased inequality between states within multilateral negotiations and processes.This situation arises because: (i) the regime complex creates multiple processes which states must navigate and some states have less capacity to do so; and (ii) states engage in forum shifting, to move issues between institutions and actors to gain more favourable outcomes.We are currently witnessing an important shift in the evolving global health security regime to new forums.Moreover, given that high-income states have influence in the regime complex of global health security, 13 the institutions involved in this area may face diminished authority.This situation has potential implications for the normative power of such institutions, particularly WHO; the way stakeholders must navigate this landscape; and ultimately meaningful global health security, which these evolving power dynamics may jeopardize.

Global health security
Clare Wenham global governance that emerge because of the coexistence of rule density and regime complexes." 14 The concept of regime complexes has been increasingly used to understand the diverse and interconnected set of rules, norms and institutions that govern global health, 11,15 including states, intergovernmental organizations, nongovernmental organizations, philanthropic foundations, civil society groups, private sector entities and academic institutions. 10These actors engage in various forms of collaboration, cooperation and competition through international law and norm setting to address pressing global health issues. 15The coexistence of multiple regimes within the global health governance landscape creates both opportunities and challenges.On the one hand, a regime complex can foster the sharing of knowledge, resources and best practices across different sectors.On the other hand, the complexity and overlapping nature of regimes can lead to fragmentation, duplication and coordination challenges.
Within global health, subregime complexes also exist including antimicrobial resistance, 16 donor health programmes, 17 donor funding, 18 pharmaceutical production 19 and global health security. 11The global health security regime has been defined as "the implicit or explicit principles, norms, rules and decision-making procedures by which international actors (including both states and civil society organizations) aim to protect their constituencies from the transmission of diseases from one area to another." 11 Based on an historical analysis of the development of the global health security regime, four key periods have been proposed: the unilateral quarantine regime in the early modern period (1500-1800); the nascent sanitary conference regime starting in the 19th century; the institutionalized sanitary coordination regime at the start of the 20th century; and the health cooperation regime starting with the founding of WHO in 1948. 11HO achieved success in its initial decades, both by consolidating regional governance mechanisms, 20 and through notable achievements such as the eradication of smallpox. 21owever, the emergence of many new actors and challenges to its legitimacy that arose from the Ebola virus disease outbreaks and the coronavirus disease 2019 (COVID-19) pandemic 9,22 suggest that WHO may no longer be seen as the primary authority within the global health security regime.This paper suggests that the catalytic trigger for a crisis of authority is COVID-19. 23Given this scenario, there may be four future trajectories: (i) greater authority for WHO; (ii) dominance by a concert of powers; (iii) global rebalancing of power among states; and (iv) civil society leadership. 11n the wake of the multiple failures in dealing with COVID-19 in many domestic and international governance settings, numerous calls have been made for the need to reimagine multilateralism to make it fit for purpose 15 -the questions are: for whose purpose, 24 and who is making the calls for new governance arrangements?Such changes will have very real effects on what the global health security regime will look like in the future.

Forum shifting
Given the proliferation of actors in the regime complex for global health security, selecting an institutional location for governance and transforming this location to serve particular interests has become a key feature of policy-making. 25orum shifting refers to the strategic process through which actors move the location of negotiations and discussions to forums or institutions which better meet their needs.The purpose of doing so can be multiple, such as: to seek more favourable outcomes; to relieve growing political pressure within other forums; to create competing norms to challenge the dominant discussions elsewhere; or to promote integration across different regimes. 26o optimize authority, and ultimately outcomes, in negotiations, states need to consider several factors including: membership; mandate; decisionmaking processes; enforcement options; organizational culture and historical development; secretariat capacity; funding arrangements; provisions for reservations to be lodged; arrangements for provision of technical or scientific advice; provisions for withdrawal; and links with other forums of governance. 27n this way, high-income countries might move negotiations to a forum where decision-making is linked to material contribution to have a greater opportunity to shape the outcome of the policy decision.Similarly, blocks of lowand middle-income states might push to move an issue into the UN system where collectively, through group coalitions, they would have more votes in a one-state one-vote model.As a result, forum shifting has profound implications for global governance and affects the distribution of power, effectiveness of decision-making, and overall coherence of policies and actions.Indeed, in effect, forum shifting can be considered to result in negotiations never really being completed. 28When a conclusion may be reached in one forum, if it is not to the interests of all involved, then a new process will emerge or the negotiations will continue in another forum.Thus, forum shifting is not only a policy development tactic, but also a manifestation of power, particularly if it is done in the absence of material power. 29

Examples of forum shifting
For some Member States, WHO and the IHR, even if imperfect, remain the core of the regime complex of global health security.These states have proposed amendments to be made to the IHR to enhance their operability and implementation.This move is being led by a working group for the IHR under the auspices of WHO.This process is centred on reviewing and redrafting legal text to improve the IHR and make them fit for purpose in the post-COVID-19 era.This approach was initially proposed by the United States of America (USA), 30 which considered the IHR a forum for governing global health security 31 because the regulations are technical public health policies 32 and they improve surveillance, 33,34 but they do not challenge sovereign decision-making. 6t the same time, the European Union (EU) proposed a new process, or indeed, a forum shift, to develop a new pandemic treaty alongside the IHR. 35This proposal was followed by a call to action to spur moves for a new instrument or convention to enhance pandemic preparedness. 36,37A special session of the World Health Assembly was therefore held in 2021, and Member States agreed to establish an intergovernmental negotiating body to start the process of negotiating an international instrument, convention or other agreement.The EU favours a new instrument, as it supports international order based on well-functioning international institutions and a rule-based approach to global issues. 38 Global health security Clare Wenham the Russian Federation and the USA did not engage in the initial dialogue on a pandemic treaty. 36,39The fact that both the IHR amendments and the pandemic treaty are occurring under the auspices of WHO may create strategic differences between various governance mechanisms.
In September 2023, the High-Level Meeting on Pandemic Preparedness and Response took place during the UN General Assembly. 40This meeting was spurred by the Independent Panel for Pandemic Preparedness and Response, 41 which noted that the UN was the appropriate forum to bring about meaningful change at the global level, given the success of interventions within the UN for the Ebola virus disease outbreaks. 42his high-level meeting was led by Israel and Morocco, with the support of some countries in the Group of 20 (G20) states that may feel without a voice within the working group for the IHR and intergovernmental negotiating body.In these latter forums, geopolitical negotiating relating to access to medicines tends to dominate between a few high-income states and the main counter-narrative of the so-called group for equity.For these states, the UN is the appropriate forum for pandemic preparedness, as it is where the heads of states meet -that is, those with political power to bring about change -and indeed, is a forum where they have had successes in other governance settings. 43WHO's governing body is the World Health Assembly, which is generally composed of health ministers with more limited mandates. 41he text of the political declaration on pandemic prevention, preparedness and response 40 bears considerable resemblance in content to the output of the intergovernmental negotiating body and working group for the IHR processes, yet the motivation for some forum shifting was to secure greater political support for pandemic preparedness and response.
Forum shifting is also occurring within global health security related to access to medical countermeasures, such as vaccines, which was arguably the biggest failure of multilateralism during COVID-19, given the considerable vaccine inequality during the pandemic. 44s such, the issue of countermeasures policy was always going to be central to any future policy development for global health security.The issue of medical countermeasures has been addressed in the various drafts of the IHR amendments, the intergovernmental negotiating body drafts, and the UN and G20 political declarations.These drafts have focused on equity to redress some of the inequalities experienced during the pandemic, with some proposals counteracting the status quo.Such policy development is particularly important within UN system forums, given the collective influence of low-and middleincome states in a one-state one-vote mechanism.Moreover, the aforementioned proliferation of forums where parallel conversations are occurring within the same system highlights the real need for low-and middle-income states to ensure their meaningful input into policy and operational content, to assure equity in access to and delivery of countermeasures in future. 45Additionally, this proliferation may suggest that some states are inclined to create strategic incoherence to avoid commitment to global equity in access to medical countermeasures.
At the same time, forum shifting is occurring in another complex regime, the trade regime.High-income states recognize that debate on equity does not necessarily align with the domestic pressures they face to deliver countermeasures to their own populations, or maintain their relationship with the pharmaceutical industry.They would therefore prefer to keep the equity issue within the trade regime of WTO and the World Intellectual Property Organization (WIPO) as their enforcement mechanisms are more stringent than WHO. 46,47Maintaining this status quo would protect pharmaceutical patents and alleviate domestic pressures.Some G20 states led by Japan, and later India, have promoted a new institutional forum, the medical countermeasures platform, using the lessons learnt from the initiative COVID-19 Vaccines Global Access (COVAX) to develop an operational location to ensure research, access, technology transfer and equity. 48This forum seeks to offer an operational solution with regard to countermeasures, but it runs the risk of being perceived as being governed elsewhere and removed from the legal processes in Geneva within WHO, WTO and WIPO, potentially creating more disconnection between this platform and the legal developments arising from the working group for the IHR and the intergovernmental negotiating body.
Given this situation, further forum shifting is occurring to regional mechanisms with, for example, the African Centres for Disease Control and Prevention becoming a new location for governance for African countries whose representative feel that they gain little from global multilateral processes. 49ach of these processes claim to be improving global health security and indeed often indicate synergies with each other.Yet, when considering the global health security regime as a whole, it can be seen that proliferation of parallel activities and forum shifting is not uncoordinated or accidental, but reflects the political drivers of multilateralism. 50ndeed, as has been predicted, 11 it would seem that a crisis of authority within and beyond WHO may be occurring.WHO is developing policy (for example, IHR amendments) at the request of Member States that recognize WHO as a comparatively non-political forum without strong political power to hold states to account, rather than the dominant actor. 51For WHO to develop policy when the decision-making authority has shifted to another forum, is futile, as is the case of access to medical countermeasures with the authority remaining with WTO.Thus, in terms of the regime complex, we are somewhere between a dominance of a concert of powers and a global rebalancing among states. 11The outcome of these ongoing processes will determine which of these scenarios emerges, and forum shifting remains a key mechanism by which states are trying to predetermine which occurs.
This forum shifting in global health security has secondary effects on WHO as an institution as it positions itself within the regime complex.Although WHO is the only multilateral institution mandated to be the international coordinating actor in global health, the potential forum shifting away from the Organization and the strategic uncertainty within it may be problematic, both for WHO and the global health security regime (Fig. 1). 22Practically, the forum shift away from WHO is at odds with the push governments are making for a strengthened WHO. 40,52Interestingly, despite being a technical organization, WHO exerts influence in these political processes and has moved within the changing forums to involve itself, such as acting as the technical lead for the pandemic fund, and the governance of the intergovernmental negotiating body Bull World Health Organ 2024;102:123-129| doi: http://dx.doi.org/10.2471/BLT.23.290480   Global health security Clare Wenham being located within the Organization.WHO is also the interim host of the medical countermeasures platform.The global health security regime complex may be placing WHO at the centre given its normative expertise as the directing and coordinating authority for international health work, to strengthen new institutions and forums.On the other hand, WHO may be accommodating forum shifting to maintain its position at the centre of the global health security regime.In the regime complex, stakeholders must act alongside each other and collaborate to maintain power and legitimacy, and deliver on their own activities.
Understanding the regime complex and forum shifting is vital to the analysis of global health security and the inequalities that continue to beset negotiation processes and policy outcomes.To engage with the multiple current processes requires analysis of the factors that influence forum selection, including power dynamics, agenda-setting processes and strategic considerations.Additionally, forum shifting affects both the effectiveness of any one process and the legitimacy of global governance for health security at large, and for WHO in particular.This understanding can help public health practitioners and policymakers develop strategies to engage politically in such processes, recognizing the political issues in play, to enhance coordination and coherence of efforts where possible and ultimately improve global health security.■ Fig. 1